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Weight-Lifters: Shoulder Strain & Science

This case study focuses on the Australian over-105kg weight-lifter Damon Kelly, who injured his left shoulder, which he had jarred while performing a mis-timed snatch. Injury scientist, Dr. Alexander Jimenez takes a look at the case.

In the snatch movement, the bar must be lifted above the head to full arm extension at one continuous rapid movement. The weight-lifter should then be held steady until the judges have accepted the lift.
While practicing, Damon had captured the pub just too far behind his head, causing a slight "shift within his gleno-humeral joint along with a sharp pain. He immediately dropped the bar and had been resting almost completely from the grab component of his training.

Damon currently presented with "stiffness" and pain, largely on reaching across his body (horizontal flexion) along together with his hands behind his back (complete operational internal rotation). All stationary muscle tests were negative, and also his shoulder elevation was ordinary, much to my relief.

He reported being able to perform shoulder press with no pain in any way, even in a moderately heavy load for him. He was, however, getting some pain with the grab position under load, and was quite apprehensive about this (it felt "weak in that position).

I have generally found that the Queensland weight-lifters I've looked after over the years are utilized to training with pain and have very low anxiety over injury. They are specialists at load- modification and development, appreciate strongly the value of correct technique, and the majority of them understand training periodization fairly intuitively.

My provisional identification was a rotator cuff "strain , using a minimum likelihood of this weight-lifter really having ripped any tendon fibers. Posterior impingement of the rotator cuff at the glenoid was a distinct possibility -- hypothetically the pain at the posterior rotator cuff may have been solely due to compressive forces and consequent tendon impingement, maybe not overstrain/ overload at end of scope.

There was also a distinct possibility that he had experienced a small anterior subluxation occasion in the snatch position, but given how quickly it was resolving, and that he noted no parasthesia or clunking/ snapping feelings at the joint, I believed that this was unlikely. Feelings of "instability in the snatch position might have had less to do with any disruption to the normal capsuloligamentous restraints into the joint than using inhibition of the rotator cuff (especially the medial rotator, subscapularis), for example that it couldn't hold the "ball as tightly in the socket as usual.

The Way The Injury Occurred

Let's picture what the position and load of the "snatch needs of the rotator cuff:

• The humerus is nearly fully externally rotated, with the supraspinatus, infraspinatus and teres minor wrapping posteriorly under the head of humerus, and even towards the anterior-inferior aspect of the ball.

• The subscapularis forms the anterior dynamic barrier to the joint, extended to its full length and playing a critical eccentric role in preventing anterior shear and excessive posterior angulation of the humerus.

With the bar quickly being forced to grab position by a strong concentric contraction of the external rotators, and abruptly coming to sit above the mind in 1 rotational movement, the strength and timing of subscapularis suddenly having to generate a huge eccentric internal spinning force has to be impeccable. If the time is repeatedly poor, or if the external rotators have slowly become too tight (a common result of some number of training variables), then subscapularis might not perform its job quite nicely enough and the ball will slightly shear anteriorly from the socket. Within a untrained shoulder, an entire spectrum of damage is possible, the worst being anterior shoulder dislocation.

Treatment

Employing deep-tissue massage and trigger- point releases, stretching and dry needling, we focused on repeatedly attaining two effects during the following four weeks, so as to restore normal rotator cuff function in the snatch position:

• The external rotators (infraspinatus, teres minor and supraspinatus) were released from excessive tension and tightness. We literally beat them into submission – which, with a guy as big as Damon, takes not a small amount of force! Each session of this treatment managed to clear his pain on horizontal flexion and internal rotation (hand behind back), indicating that the muscles were returning to a normal state of function and length.

• We trigger-pointed the internal rotator (subscapularis) to activate it, to bring it to life from its relatively dormant state. Lying deep in the axilla, with overlying layers of superficial muscle and fascia, it is a real challenge to get into this muscle.

This treatment -- subduing overactive external rotators and triggering a dormant subscapularis -- for me clinically forms a common routine in sport injury.

Aiding Activation

On the very first day I saw Damon, I began experimentation by having him hold the bar in the grab position with elastic tube tensioned to pull the bar back over his head behind him (see Figure 1). He found that this instantly gave him a feeling of "security together with his joint under load. The pull of the tubing enhances the stimulation of subscapularis, so it can be used to centralize the job of this gleno-humeral joint by neutralizing the rotational forces of the cuff. In effect it provides a boost to the less powerful or inhibited subscapularis.

Damon continued to utilize the tubing for 3 weeks since he slowly increased his holding time in snatch standing and introduced the snatch movement with progressively increasing heaps. Then he used the tubing only during warm-up, and finally weaned himself off it entirely using a week to spare before his next contest.

Trainers and gym-goers can certainly use the tubing concept themselves at bench press and shoulder press. First implement a standard shoulder press with the bar, then attach a moderate strength of tensioned tubing to pull the bar from beneath, and see how "smooth and "simple the press movement now feels. It's nearly as though the socket has abruptly been lubricated, as the load requirement for your external rotators is reduced, and the subscapularis has been requested to step up and function. It certainly worked for Damon Kelly, with nearly 200kg over his head.

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